Instruction Sheet Physician – Licensure by Acceptance - Illinois ...

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PART III - CERTIFICATION OF EXAMINATION SCORES A1. National or other Profession Specific Examination (Record all available information) Date of Examination ___________________ A 2. Scaled Score __________________ Raw Score ___________________ Standard Deviation __________________ Corrected Score ___________________ National Mean __________________ Percent Score ___________________ SUBJECT DATE B. State Constructed Examination SUBJECT DATE SCORE SCORE SUBJECT DATE SUBJECT DATE SCORE SCORE PART IV - FORMAL ACTIONS A. Is there now or has there ever been any formal action commenced against the applicant? Yes No B. Have there ever been any formal sanctions imposed against the applicant as a matter of public record including but not limited to fine, reprimand, probation, censure, revocation, suspension, surrender, restriction or limitation? (If yes, attach a certified copy of disciplinary action.) Yes No PART V - RECIPROCAL REGISTRATION This state does does not grant the same privilege of reciprocal registration to Illinois registrants. I certify that the information contained herein is true and correct according to the official records of the State. S E A L IL486-0850 04/06 (LT) Print Name Title Agency/Board Street Address City, State, ZIP Code Signature Date Area Code ( ) Telephone Number Attention Licensing Agency/Board: RETURN THIS FORM TO THE APPLICANT. Attention Applicant: FOR INCLUSION WITH APPLICATION PACKET. CT - Certification by Licensing Agency/Board - Page 2 of 2 NAME (Last, First, MI): ______________________________________________ SS#: _____________________ Profession: ___________________
IMPORTANT NOTICE: Completion of this form is necessary for consideration for licensure under 225 ILCS 60/1 et. seq. (Illinois Compiled Statutes). Disclosure of this information is VOLUNTARY. However, failure to comply may result in this form not being processed. APPLICANT: Complete the applicant section of this form, then forward it to the appropriate official for completion of A or B. 1. NAME LAST FIRST MIDDLE 4. ADDRESS STREET, CITY, STATE, ZIP CODE 6. MAIDEN OR GIVEN SURNAME IL486-1417 07/02 (L&T) CERTIFICATION OF AFFILIATION SUPPORTING DOCUMENT AF-MED 2. DATE OF BIRTH 3. SOCIAL SECURITY NUMBER __ __ / __ __ / __ __ __ __ Month Day Year __ __ __ - __ __ - __ __ __ __ 5. REFER TO REFERENCE SHEET. Record profession name and three digit profession code for which you are making Illinois application. Profession Name DEAN OR ADMINISTRATOR OF CLINICAL TEACHING FACILITY Read A and B below, then complete either A or B and return form to the applicant. Profession Code A. MEDICAL COLLEGE: If the clinical teaching facility in which the applicant performed his core clinical rotations (internal medicine, surgery, pediatrics, obstetrics-gynecology, psychiatry) was owned or operated by the medical college from which he graduated, sign the certification below. CERTIFICATION I hereby certify that the core clinical rotations of the above-named applicant were conducted in a clinical teaching facility owned or operated by the medical college from which he graduated and that the applicant was enrolled in the medical college during the course of these core clinical rotations. S E A L OF COLLEGE Signature of Dean of Medical College Type Name of Dean of Medical College Date Name of Medical College Street Address City State Zip Code B. CLINICAL TEACHING FACILITY: If the clinical teaching facility in which the applicant performed his core clinical rotations (internal medicine, surgery, pediatrics, obstetrics-gynecology, psychiatry) was formally affiliated or contracted with the medical college from which he graduated, sign the certification below. Further, you must submit a copy of the affiliation agreement between the hospital and the medical college which conferred the degree and a copy of an evaluation form for each core clerkship rotation, which was completed by the supervising physician of that rotation. CERTIFICATION I hereby certify that the core clinical rotations of the above-named applicant were conducted in a clinical teaching facility formally affiliated or contracted with the medical college from which the applicant graduated and that the applicant was enrolled in the medical college during the course of these core clinical rotations. S E A L OF INSTITUTION Signature of Administrator of Clinical Teaching Facility Type Name of Administrator of Clinical Teaching Facility Date Name of Clinical Teaching Facility Street Address City State Zip Code
Page 1 and 2: Instruction Sheet Physician - Licen
Page 3 and 4: PERSONAL HISTORY INFORMATION INSTRU
Page 5 and 6: Education Requirements (cont’d) G
Page 7 and 8: FCVS will charge you a fee for gath
Page 9 and 10: Applicants Using FCVS (cont’d) Ap
Page 11 and 12: Applicants Not Using FCVS (cont’d
Page 13 and 14: LICENSURE METHODS AND DEFINITIONS F
Page 15 and 16: Illinois Department of Financial an
Page 17 and 18: PART III: Education Information 1.
Page 19 and 20: PART VI: Personal History Informati
Page 21 and 22: * DEFINITIONS 730 ILCS 150 et. seq:
Page 23 and 24: IMPORTANT NOTICE: Completion of thi
Page 25: IMPORTANT NOTICE: Completion of thi
Page 29 and 30: IMPORTANT NOTICE: Completion of thi
Page 31 and 32: If you hold a non-renewed controlle
Page 33: PART V: Personal History Informatio

Instruction Sheet Physician – Licensure by Acceptance - Illinois ...

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